A frail 85-year-old patient with atrial fibrillation on direct oral anticoagulants presented with fever and acute dyspnoe and was diagnosed with right upper lobe pneumonia. (Fig. 1A) The patient´s condition stabilized on antibiotics. However, the detailed history included un-investigated dysphagia and nocturnal regurgitation of food was reported. Zenker´s diverticulum was confirmed by esophagogram suggesting a 60 mm hypopharyngeal pouch (Fig. 1B), reproduced on endoscopy (Fig. 1C; arrow esophageal entrance) with food retention at its base. (Fig. 1D) Endoscopic myotomy was scheduled two weeks later to allow for pneumonia resolution. However, the patient was readmitted three days prior with recurrent aspiration pneumonia. The patient additionally reported chest pain with troponin dynamics, suggesting non-ST elevation myocardial infarction. The patient underwent interventional coronary revascularisation with implantation of two drug-eluting stents with triple antithrombotic treatment until discharge. In this complex scenario, the patient was trained by speech therapy and instructed to only eat soft meals, avoid late meals and post-prandial recumbency. Endoscopic treatment was provisionally postponed for three months in case peri-interventional bleeding complications may arose. As a consequence, the patient did not experience further pulmonary complications and presented for endoscopic myotomy under the P2Y12 inhibitor clopidogrel, while apixaban was withheld 24 h. Endoscopic myotomy using a transparent cap to facilitate endoscopic maneuvering started with mucosal incision over the cricopharyngeus muscle, the fibres of which were rapidly identified underneath. (Fig. 2A) The whole procedure was performed using an articulating knife allowing for rapid and precise transection (ClutchCutter device, Fuji, Düsseldorf, Germany). (Fig. 2B) Despite the large size, a complete myotomy, was performed within an estimated 15 min without complications and with complete resolution of the diverticulum. (Fig. 2C) The postinterventional course was unremarkable. At clinical follow up after three months, the patient reported complete absence of dysphagia.
To read this article in full you will need to make a payment
Purchase one-time access:Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
One-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:Subscribe to The American Journal of the Medical Sciences
Already a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
- Severe pulmonary disease subsequent to Zenker's diverticulum.N Engl J Med. 1955; 253: 209-212
- Flexible endoscopic Zenker's diverticulum treatments - too many in the tool box?.Endoscopy. 2021; 53: 354-356
- Endoscopic therapy of Zenker's diverticulum using a novel endoscopic scissor - the clutch cutter device.Endoscopy. 2015; 47: E430-E431
Published online: September 29, 2022
Accepted: September 26, 2022
Received: December 21, 2021
© 2022 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.